Geriatric Nursing 36 (2015) 21e24

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Feature Article

Nurses’ knowledge and comfort levels using the Physician Orders for Life-sustaining Treatment (POLST) form in the progressive care unit Nancy N.H. McGough, PhD, RN a, *, Barbara Hauschildt, MSN, RN, NE a, Deene Mollon, PhD(c), RN, NE-BC a, Willa Fields, DNSc, RN, FHIMSS a, b a b

3 East Progressive Care Unit, Sharp Grossmont Hospital, 5555 Grossmont Center Drive, La Mesa, CA 91942, USA School of Nursing, San Diego State University, San Diego, CA, USA

a r t i c l e i n f o

a b s t r a c t

Article history: Received 19 May 2014 Received in revised form 1 September 2014 Accepted 8 September 2014 Available online 16 October 2014

Many patients are admitted to the hospital with an active Physician Orders for Life-sustaining Treatment (POLST) Form; however, not all registered nurses (RNs) are familiar with the form or comfortable with initiating a discussion about end-of-life care. Evidence indicates that an education program increases RNs’ knowledge and utilization of the POLST form. The purpose of this evidence-based practice project was to answer the question: among the RNs in a progressive care unit (PCU), does implementing a formal evidence-based practice POLST program compared to current practice increase RNs’ knowledge and comfort level using the POLST form? A pre-post education survey was used. Results indicated a POLST education program increased PCU RNs’ knowledge and comfort level in using the POLST form. It is recommended to include POLST form education for PCU RNs in workplace education programs. Ó 2015 Elsevier Inc. All rights reserved.

Keywords: POLST Progressive care unit End-of-life Evidence-based practice

Introduction The majority of Americans say it is extremely important to be comfortable and pain free when approaching death.1e3 Medicare beneficiaries received an average of 21 days of hospice care in the last 180 days of their life.4 The majority of Americans prefer a natural death, in a familiar environment, with loved ones, and without interventions to prolong life or delay the dying process.1e3 During the last 180 days of life, 15% of Medicare beneficiaries spent more than seven days in the intensive care unit where they received aggressive, life prolonging medical treatments. Approximately 42% of them saw more than ten physicians, suggesting intense medical interventions.4 A discrepancy exists between end-of-life wishes and the actual care a patient receives. There are multiple reasons explaining the gap between a patient’s wishes and the care they received during their last six months of life. Factors such as race,5,6 culture,6 and age7 affect the likelihood a patient’s end-of-life treatments will be in accordance with their preferences. Barriers exist for discussions among health care providers, patients, and their families about end-of-life care. Barriers include time for health care providers to spend with a patient8 and inadequate training for health care providers in

* Corresponding author. Tel.: þ1 619 740 4840; fax: þ1 619 740 4257. E-mail address: [email protected] (N.N.H. McGough). 0197-4572/$ e see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.gerinurse.2014.09.001

end-of-life care discussions.9 Even when these discussions occur, a patient’s wish might not be documented or followed through by other health care providers in a different health care setting.8,10 The Physician Orders for Life-sustaining Treatment (POLST) form complements an advanced directive to ensure the patient’s preferences about end-of-life care are followed in any health care setting. The purpose of this evidence-based education program was to increase progressive care unit (PCU) registered nurses’ (RNs’) knowledge and comfort levels using the POLST form. Background The POLST form was initiated in 1991 when a group of medical ethicists in Oregon noted patients’ preferences for end-of-life care were not consistently honored.11 A new tool, the POLST form, was developed to facilitate end-of life communication between a patient and health care providers, translate patients’ end-of-life goals into medical orders and ensure patients’ wishes are honored across health care settings.11,12 POLST is specifically for patients who have life-limiting illnesses and are in the last year of their life.11 Currently, 16 states have implemented a similar legal provider order form documenting parameters for life-sustaining treatment and 27 more states have programs in development.12 Although the POLST form has been established or is being developed in most states with the same core concepts, the form goes by different names and under different legislation regulations

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in different states.13 Besides POLST, for example, Delaware, Maryland, Massachusetts, New York, Ohio and Rhode Island use medical orders for life-sustaining treatment (MOLST); Idaho, Indiana, South Carolina, Tennessee, Virginia and West Virginia use physician orders for scope of treatment (POST) and Alaska, Colorado, Kentucky, New Mexico and North Carolina use medical orders for scope of treatment (MOST).13 In some states (California, Georgia, Illinois, Kansas, Missouri, Nevada, New York, Tennessee and West Virginia), only physicians can sign and validate the POLST form. However, other states (Colorado, Iowa, Idaho, Maryland, Massachusetts, Minnesota, Montana, New Jersey, North Carolina, Oregon, Rhode Island, Utah, Vermont and Washington) extend the authority to sign the POLST to nurse practitioners or physician assistants.13 Based on California law AB 3000 (Statutes 2008, Chapter 266), although nurses are unable to sign the POLST form, nurses are able to initiate a discussion on the content of the POLST form. Three core tasks need to be accomplished between health care providers and a patient when using a POLST form in the state of California.12 First, health care providers (e.g. physician, RN, social worker) need to discuss preferred end-of-life medical interventions such as resuscitation, antibiotics, intubation, and tube feedings with their patient. Second, health care providers need to document the patient’s choices on the POLST form, which is then signed by the patient and physician. Although the POLST form was initially a bright pink document so it could be recognized easily within a stack of patient medical records, it does not need to be pink to be valid. The physician’s signature authenticates the POLST form into actionable physician orders, which then can be followed by other health care providers at any location at any time. Third, the POLST form accompanies the patient when transferring between health care settings such as a skilled nursing facility (SNF) or acute care hospital. Health care providers are bound by the orders in the POLST form. Patients admitted to the hospital with a POLST form are less likely to receive unwanted or medically ineffective treatment and have less patient and family suffering when compared to patients who had only an advanced directive.14 Due to the size and ethnic diversity in California, the POLST form was implemented through local community coalitions which focused on promoting its usage in SNFs.15 In 2007, the California HealthCare Foundation collaborated with the Coalition for Compassionate Care of California and funded seven community coalitions to perform grassroots education and training about POLST form usage. In 2008, additional eleven community coalitions were funded.15 In 2009, California law AB 3000 (Statutes 2008, Chapter 266) required physician orders in a POLST form16 to be followed by health care providers. Based on the report from Wenger et al, 82% of California SNFs educated their staff about the form, and 80% of the SNFs’ residents completed a POLST form after admission.15 San Diego County is one of the POLST community coalitions regions. More and more SNF residents were transferred to the acute care hospital with a POLST form. However, many of the RNs in these hospitals were not familiar with how to use this form and not comfortable in talking to the patients or their families about the end-of-life care content in the POLST form. Sharp Grossmont Hospital is a 536-bed acute care hospital in East San Diego County, California. There are more than 35 SNFs in this geographic area. This project took place in two of the hospital’s 33-bed PCU. The majorities of patients are admitted through the emergency department and have congested heart failure (CHF), chronic obstructive pulmonary disease (COPD), pneumonia, gastrointestinal bleed or alcohol withdrawal. The units are staffed with nine RNs, three nursing assistants, one resource RN, one charge RN and one monitor technician for each 12-h shift.

Problem description The RNs at Sharp Grossmont Hospital had not received POLST form training. Although the POLST form was included in the transfer documentation with a patient from a SNF, the RNs in the hospital did not know what to do because they were not familiar with the information provided on the form. For example, they did not know which orders to follow when there was a discrepancy between the resuscitation order on the POLST form and the order from the admitting physician. Additionally, the PCU RNs often suggested physicians order palliative team consults so the PCU RNs did not have to discuss end-of-life care with the patients or their family. Workplace education on advanced directives has been shown to increase RNs’ knowledge and facilitate positive experiences in endof-life care.17 Vo et al18 compared health care providers’ characteristics between SNFs with high and low POLST form completion rates. In SNFs with higher POLST form completion rates, the health care providers had higher knowledge about the POLST form and were able to use this form more successfully. Therefore, this evidencedbased practice project focused on answering the question: among the RNs in the PCU, does implementing a formal evidence-based practice POLST program compared to current practice increase RNs’ knowledge and comfort level using the POLST form? Methods Project design and sample This evidence-based descriptive project evaluated RNs’ usage, knowledge and comfort level using the POLST form pre- and posteducation. The POLST form education was mandatory. Participation in the pre- and post-education surveys was voluntary. After receiving approval from the Institutional Review Board, volunteers were solicited to participate in the online survey via email and posted flyers in each unit. The email and flyers included a description of the project and a link to the survey. All 105 RNs employed and not on leave in both PCUs were sent the email. Participants consented to participate by completing the survey. No identification information was collected from RNs in the online survey. There was no match in the participants pre- and post-survey. Intervention The education was delivered at a mandatory staff meeting and included a 12 min “POLST at Work in California” video from the California POLST website (http://capolst.org/polst-for-patientsloved-ones/), followed by a 20 min slide presentation and discussion. The video focused on providing knowledge about the purpose of the POLST form, the basic concepts of the POLST form, the medical interventions listed in California’s POLST form, and an example about how the POLST form travels with the patient in the health care system so the patient’s wishes are honored by all health care providers. The slide presentation concentrated on the differences between the POLST form and an advanced directive, example dialogues discussing each section of the POLST form, and a scenario of a patient admitted to the hospital with a POLST form. To assist those who were not able to attend the staff meeting and to reinforce the education to those who attended the staff meeting, the link of the video was emailed to all PCU RNs via the hospital’s internal email system. An educational poster board with the information in the video and slide presentation was reviewed with individual RNs who missed the staff meeting. Additionally, the poster board was displayed in each unit for the PCU RNs to review for one month after the staff meeting.

N.N.H. McGough et al. / Geriatric Nursing 36 (2015) 21e24

Likert-like scale questions. Chi-square was used to compare the data from yes or no questions. Descriptive statistics were employed to analyze the demographic data.

Table 1 End-of-life experience. Question

Experienced at least one time in the past two months Pre-education % (n) N ¼ 30

Asked to complete or administer POLST Asked to honor POLST in the hospital Asked to ignore POLST/ Advanced directive by family Met with family about end of life decisions Met with patient about end of life decisions *

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Significance level ManneWhitney U

Results

Post-education % (n) N ¼ 24

6.7 (2)

37.5 (9)

0.006*

43.3 (13)

79.1 (19)

0.01*

10.0 (3)

8.3 (2)

0.84

60.0 (18)

75.0 (18)

0.29

53.3 (16)

70.8 (17)

0.15

p < 0.05.

Measures The 29 item survey was adapted from the Nursing Home Employee Anonymous Survey.18 The online survey was available 10 days before and 8 weeks after the POLST education. Each survey was available for 10 days. The survey contained four sections: end-of-life experience, POLST form knowledge, attitude toward end-of-life care, and demographic information. The end-of-life experience section included five questions about how frequently (never, 1e2 times, 3e5 times, greater than 5 times) RNs honored, completed, and initiated a discussion about the POLST form or end-of-life decisions in the past two months. The knowledge section included two true/ false/do not know questions on the color of the POLST form and the requirements for physician signature. The attitude section included 12 Likert rating scale questions (1 ¼ strongly agree to 5 ¼ strongly disagree) on attitudes about the POLST form. The 10 demographic questions included information such as age, gender, years in the nursing profession and training received on POLST form usage. Data analysis SPSS version 21 was used to analyze the survey results. Manne Whitney U test was used to compare pre- and post-survey data in

Thirty-two PCU RNs (30%) completed the pre-survey while 31 PCU RNs (30%) completed the post-survey. Two pre-survey and seven post-surveys were excluded from further data analysis because those RNs answered “No”, “Don’t know” or skipped the question “have you received an in-service about the POLST form.” The only significant difference between the pre- and post-survey participants was for gender; 10% (n ¼ 3) of the participants were male in the pre-survey and 4% (n ¼ 1) in the post-survey. The majority of the participants were under the age of 40 (80% vs. 79%, n ¼ 24 vs. 19) and have been in the nursing profession for less than 5 years (63% vs. 58%, n ¼ 19 vs. 14). After POLST education, the PCU RNs reported a higher frequency in completing a new POLST form (p ¼ 0.006, Table 1) and honoring patient wishes by following an existing POLST form (p ¼ 0.01). The frequency of ignoring an existing POLST form based on patient family’s request (p ¼ 0.84), discussing end-of-life decisions with patients (p ¼ 0.29) or their families (p ¼ 0.15) were not changed. After POLST education more RNs reported feeling comfortable initiating discussions about the POLST form (p ¼ 0.01, Table 2) and completing a POLST form with the patient (p < 0.001) while less RNs felt the length of the POLST form made it difficult to complete (p ¼ 0.046). The RNs were also more aware of no color requirement for the POLST form (p < 0.001, Table 3). There was no statistical difference in the RNs’ attitude toward end-of-life pain management and care, who should discuss the POLST form with the patients, comfort level performing a family conference and knowledge about the requirement for a physician signature on the form. Discussion This evidence-based project indicated POLST education increased PCU RNs’ knowledge and comfort level in initiating discussions with a patient about the POLST form as well as the frequency in completing a new POLST form in the PCUs. This project demonstrated a practical and easy to follow unit-based protocol for anyone who wants to increase RNs’ knowledge and comfort level in using the POLST form. Research has demonstrated that there are positive relationships between knowledge and usage of the POLST form,18 knowledge and the attitude in using advance directives,17 as well as knowledge and end-of-life care.19 Continuing education is one way to increase RNs’ knowledge. Continuing education can improved RNs’ knowledge

Table 2 End-of-life attitudes. Question

Patients have POLST has better pain control Long-term hospital patients should have a POLST form It is Social Worker’s responsibility to discuss the POLST It is Nurse’s responsibility to discuss the POLST It is Physician’s responsibility to discuss the POLST The length and detail of the POLST make it difficult to full out Feel comfortable to initiate a conversation about the POLST form Feel comfortable performing a family conference Feel comfortable filling out a POLST form with a patient *

p < 0.05.

Agreement of the statements/þDisagreement of the statements Pre-education positive % (n) N ¼ 30

Post-education positive % (n) N ¼ 24

46.7 83.3 50.0 23.3 93.3 20.0 46.7 43.3 26.7

58.3 95.8 37.5 43.5 100.0 66.7 70.8 41.7 70.8

(14) (25) (15) (7) (28) (6)þ (14) (13) (8)

(14) (23) (9) (10) (24) (16)þ (17) (10) (17)

Significance level ManneWhitney U

0.4 0.09 0.76 0.15 0.70 0.046* 0.01* 0.34